Exercise and breast cancer

Kellie Curtain [00:00:05] Let's be upfront about exercise and breast cancer. We all know that staying active is good for you both physically and mentally. But what about when you have breast cancer? When should you exercise? What type of exercise should you be doing and how much of a difference does it really make? Not so long ago people with breast cancer were told to rest during active treatment. Now it's the opposite. In this episode of Upfront, we're going to find out why health professionals now consider exercise to play a powerful part in the treatment and ongoing management of breast cancer. Joining us is Associate Professor Prue Cormie, an exercise physiologist who is at the forefront of research in this area. We also welcome breast cancer survivor Jo Francis. Jo's been diagnosed with breast cancer twice 15 years apart, and got very different medical advice about exercise each time. The first time round exercise was not encouraged. More recently exercise has been an important part of the treatment process and her life beyond cancer. Welcome to you both.

Prue Cormie [00:01:11] Thank you.

Kellie Curtain [00:01:13] So Jo let's just take us through. You were diagnosed in 2001 for the first time and you had treatment and you were told to rest.

Jo Francis [00:01:25] I was I was 26. I had actually just studied Applied Science in Human Movement. So I was very active and working in the regime... You know in that area. And yes. So when I had my chemotherapy I was told to go home and get as much rest as possible. That was quite confronting for me because I was a very active person. I was playing basketball right up until the day of diagnosis. And for me just to be told to stop, which in my head I thought "well I've got to you know trust in the professionals and what they were telling me". And so I did what they they told me and that literally meant stopping. So I was a personal trainer. I was doing fitness classes I was working at the Harold Holt swim centre back then very active up at five o'clock in the morning. So literally within, you know, on the day of diagnosis I had to stop everything.

Kellie Curtain [00:02:19] How did that make you feel?

Jo Francis [00:02:22] At the time I think dealing with a cancer diagnosis was a real shock. So although my mother had also been diagnosed with breast cancer at 44, years ago, so I knew a lot about it but I to be told that my lifestyle had to stop. So I was working in the gym and then I had to go and work on reception. So even that for me was a very different sort of process for me to, you know, deal with. So I was very active and I think it's really you know it's a very important part of your mental health. Yeah but I did what the doctors told me and did that for probably twelve months.

Kellie Curtain [00:02:56] Prue, things have certainly changed haven't they? Why has the train of thought within the medical fraternity changed?

Prue Cormie [00:03:06] Yeah it's it's completely backflipped on that advice. It's a full 360 from that. We know now that's probably advice that would be harmful to people with breast cancer. So if you were told the same thing today you would experience worse cancer related fatigue. You'd experience much more physical conditioning. You'd experience a lot worse mental health outcomes, a lot of distress, stress, depression and anxiety symptoms and your overall quality of life would be poorer. The reason why the the actual advice has shifted so much is because we have evidence to show that withholding exercise is actually harmful. That now exercise is probably the best medicine someone with breast cancer can take in addition to their standard cancer therapies. And that's because we know that that women who exercise after diagnosis of breast cancer have fewer and less severe treatment related symptoms that I'm sure you would have experienced.

Jo Francis [00:04:05] Yeah definitely. Everything you just said then, fatigue, everything. You know I was a very fit healthy person and then all of a sudden when I stopped everything.

Prue Cormie [00:04:13] And at 26. You don't expect to feel fatigue.

Jo Francis [00:04:16] No not at all. Absolutely not no. That wasn't me. Yeah. And yeah by not doing anything I think that just it was a continuation of just getting worse and worse and worse. But I just thought it was the treatment as well.

Prue Cormie [00:04:27] Yeah absolutely and that's and that's what it is. It is the treatment that does these things we know that exercise actually works to counteract those negative side effects of the treatment. The other thing that we do know though is that it's not just about managing those side effects. There's also observational data and research that shows us that women with breast cancer who exercise more after a diagnosis have a lower relative risk of their cancer coming back and they have a lower relative risk of dying from breast cancer.

Kellie Curtain [00:04:57] Okay so what constitutes exercise.

Prue Cormie [00:05:01] Yeah it's a really this is a really important point to get across today. So exercise is one word in the same way that cancer is one word. Cancer's one word that encompasses so many different experiences and exercise can be the same. So there is no one size fits all approach that's appropriate for breast cancer patients. What's really important to remember is that evidence that comes from the scientific research that shows these benefits comes out of exercise that is done at a moderate intensity. Which means that you need to be working somewhat hard to hard. So puffing, sweating a little bit. Your heart rate's beating faster than it normally would.

Kellie Curtain [00:05:43] So it's not a stroll.

Prue Cormie [00:05:44] It's not a stroll you know and unless you're Beyonce and you can sing and dance on stage you can't maintain a normal conversation while you're walking. So it's a brisk walk while your something like you're running late for a really important appointment. That is really important in terms of doing a moderate intensity. Doing it regularly is really important as well. So making sure that it's not just one off exercise and also what's really important that's so often overlooked is that resistance exercise is a core component of the benefits that we see coming out of women with breast cancer have actually benefit from exercise.

Kellie Curtain [00:06:19] So we're talking weights?

Prue Cormie [00:06:20] It's lifting weights. Yeah it doesn't necessarily have to be in a gym but that's usually the ideal place to be so you can control the safety and make sure it's really efficient in terms of what type of exercise. But it is, it's lifting weights weight bearing activity. We are actually stressing the muscle at an intensity that prompts these changes within our bodies to allow us to actually counteract the negative effects of cancer and its treatment.

Kellie Curtain [00:06:46] Okay so that's what I was going to ask So you've got your cardio vs. changes to the muscles. So that's the bit that's having the really big change?

Prue Cormie [00:06:57] So they know it's both. So and again there's no you know exercise is not one medicine it's a whole range of different medicines. So we know from a whole bunch of of science and not just in breast cancer but we know that exercise positively influence basically the structure and the function of all of our body systems and it does it simultaneously. There's really no other medication or therapy that can positively influence as many body systems as exercise can. Now.

Kellie Curtain [00:07:27] And it's free sort of.

Prue Cormie [00:07:28] Yeah. And if you get the expert advice and you know if for example as an exercise physiologist we understand what happens inside our body when we exercise. So by having that understanding we can prescribe exercise in the same way that any doctor prescribes any kind of medication. So it's a specific type of exercise at a precise intensity or difficulty, at a volume or how much and that's based on what we call a mechanism of action or specific change that happens. Now muscles and cardiovascular system are hearts and our lungs and a dosage if you like. And all that's really finely tuned to make sure that we're targeting certain changes that could be really relevant for you vs the next person who comes in the door.

Kellie Curtain [00:08:17] So that is clearly the difference between an exercise physiologist and a personal trainer.

Prue Cormie [00:08:25] So there's a lot of wonderful exercise professionals out there and and first of all let me say very clearly that any activity is better than no activity. So you know if whatever you can do and whenever you can do it so your capabilities will change throughout your treatment and recovery from treatments so any activity good activity. If you want to maximize the benefit you get from your exercise, seeking professional help is is certainly the best thing that you can do to do that. There's so many exercise professionals out there and it's really hard to know who to go and see. So personal trainers are trained to work generally with healthy people who don't have any health concerns. An exercise physiologist on the other hand is someone who specifically trained to go through university and go through four or five years of university and is accredited as an allied health professional and they specifically learn how to actually prescribe and deliver exercise to people with health concerns.

Kellie Curtain [00:09:25] Jo the second time that you were diagnosed which was just a few years ago, you did embrace exercise because that was part of the new school of thought. What did you do and how did it change your recovery?

Jo Francis [00:09:42] Yeah. So when I was diagnosed the second time we decided to we opted for a double mastectomy which you would think would stop you from exercising or you would be told not to. But from day dot, both my plastic surgeon and my breast surgeon both suggested exercise would be great when I was up to it. So it was important for me to be getting out of bed as soon as I could, walking around moving as much movement as I could with my arms. It was a 10 hour operation so it was actually very taxing on my body. I was obviously on some medication that didn't make me feel particularly great at times but I always made sure that I would get up, walk down the corridor, which, even when I was having my chemo I was told not to do. Which you could do, you didn't have drainage tubes everywhere. So the school of thought now... And I had the physio coming in every day. You know just those kind of things were very different to my first time around. I found from also day dot by exercising my mental health was dramatically better. I fell in a heap first time round to be completely honest. I was fine through my treatment but then as soon as it stopped ,... Again I wasn't exercising because I was still told to rest until you know my body got back to normal. When you don't do it for a while then you tend to just not do it.

Kellie Curtain [00:11:05] So the motivation's gone, isn't it?

Jo Francis [00:11:07] Absolutely. So I really fell in a heap and it was awful. I had depression and anxiety. I was... Which again was not me. And slowly worked my way back and realized... I was on anti-depressants the first time. And then I think it was about three years later I decided to try about getting back into exercise, back into netball, basketball, the gym. And as soon as I started doing that I just saw the benefits straight away and could actually wean myself off my medication. This time round I was a bit concerned. I had two small children who were 3 and 5 at the time and I thought how are we going to cope with this? But the exercise I was doing my mental health has not even wavered one bit. I mean I've had I've had days but they've just been days. It hasn't been you know, weeks of not wanting to get out of bed. And I really do. I guess I a lot of a lot of that probably stems from being very physical. When I'm back playing netball with the school mums and just things like that. It's just getting out and doing something for yourself as well. And I would never have thought two years ago I'd be, you know, running around a netball court with new boobs and you know my stomach half cut. And just you know it was it was a really proud moment for me to be able to do that and also be encouraged by my medical team.

Prue Cormie [00:12:20] Absolutely. It's really funny that you know but as as when we normally expect everybody expects to get better physically when we exercise. The mental benefits are massive and that's your experience is not unique. It's so common to all of the breast cancer patients that we work with. And we know this from from scientific evidence that that exercise does lower the severity of any kind of depressive symptoms and lower the rates of depression and anxiety. We know this is not the case just fall for breast cancer patients but people in general. Exercise is a first line treatment approach.

Jo Francis [00:12:56] And endorphins. I was speaking to someone this morning about that and we were discussing that first time round when I was exercising a lot, you've got all these positive endorphins going around then when you stop that stops. So that has a huge impact on you. Second time around when I was exercising you know those endorphins are back and it's it's a natural drug I guess in conjunction with what I had to go through, what I had to take and I listened to my medical staff. But that was probably one of the best pieces of advice that I got and was completely out of the blue because I just expected them to turn around and say to me now go home and rest. Take it easy. Don't, you know, this time is completely different.

Prue Cormie [00:13:33] And it gives you an opportunity to participate in your care. You've got this active choice to actually say hey I'm going to do something to try.

Jo Francis [00:13:41] I actually had to do the dishes. Yeah I had to get up and do couldn't get out. Yeah that's right.

Prue Cormie [00:13:48] Incidental exercise.

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Kellie Curtain [00:14:06] Jo was quite active before her initial diagnosis and that's great for people who are into their fitness and are active. What about those that aren't? So they're not really fit. And that's sometimes a bit of a snowball effect because then you get the guilt. Women that might be a little bit overweight, like I should exercise and the health professionals saying you got to lose weight either either before surgery or to stop recurrence. So how do you approach... What's the first step for someone that's really not into exercise?

Prue Cormie [00:14:45] The first thing is to acknowledge that it's daunting. It's scary starting an exercise program. You know you're usually going into a place where everybody knows what they're doing they all look super competent. This is it's everybody goes in when you first start. Everybody goes in being quite terrified of starting.

Kellie Curtain [00:15:02] Everyone in their activewear.

Prue Cormie [00:15:04] Yeah exactly. Exactly. So it's it's a really really common thing to feel scared of initiating an exercise program. We work with so many women who have never before even put on a pair of runners. Who've never worn active wear and still won't wear active wear. You don't need to. But that's that's the norm. You know I think it's unusual to probably have someone as active as you before the cancer diagnosis coming in. So it's first of all I would say that.

Jo Francis [00:15:33] Because I was young as well. I think you know being so young that's why I was active whereas my. Yeah I think that probably played a little bit of a part in it. I wasn't as active second time. I'm still active but I was running after two small kids, I was 43.

Kellie Curtain [00:15:47] Likes in the way.

Jo Francis [00:15:48] That's it.

Prue Cormie [00:15:48] So yeah you have all the normal things that every barriers that everybody has to engaging exercise. On top of that then you're going through this really horrific experience which takes a massive toll on you physically and mentally. And it makes it even harder that that road is even steeper to get engaged in exercise. I would absolutely recommend that someone who's who's in that situation to then seek out professional help. If you go and see an exercise physiologist who's got experience working with breast cancer patients they'll be able to chaperone you through that process. We've done a lot of research with women who've never before exercised and they'd always talk about having that structure and support as really essential components to actually initiating that habit and and learning how to exercise and learning why to exercise and then feeling the benefits and finding that intrinsic motivation to say hey I'm going to prioritize this. This is going to be really important for me to look after me.

Kellie Curtain [00:16:47] Perhaps the thought there is you don't have to go and throw yourself into that gym.

Prue Cormie [00:16:54] No!

Kellie Curtain [00:16:55] Format which can be you know very intimidating especially when you're doing weight resistance that can actually be low impact if you like but the weight bearing still have fantastic effects.

Prue Cormie [00:17:10] There's there's so many different ways to actually exercise and no one way is going to work for all women. There's no right or wrong way. There's there's ways that will be more beneficial for you and probably more efficient in terms of getting the results that you want. But again if you just have one... It's just one conversation with an exercise physiologist, a professional who knows what they're talking about. Who can tailor the exercise advice specific to you and your circumstances. And that's really critical to then helping people actually get going with the exercise program.

Jo Francis [00:17:45] And it's really important to know where to go for that information. So I guess I was told to exercise but I was never told how or who to go to where to get the advice. Maybe I didn't sort of seek it either because I knew a little bit more about it but I think that's really important for someone who's diagnosed and going through this to actually know where to go to get the appropriate information for their appropriate diagnosis.

Prue Cormie [00:18:09] Absolutely. And that's and that's not uncommon either. So. So exercise physiologists and physiotherapists are the most appropriate health professional to be seeking out this advice from.

Kellie Curtain [00:18:19] And is that via a GP or direct?

Prue Cormie [00:18:22] You can call up straightaway. You can look up there's online directories and we can we can put some links I assume next to the podcast. Online directories for finding an exercise physiologist close to you pop in your postcode and you can find someone who's close to you. And there's also directories that we can share where people have actually learnt how to work with breast cancer patients. They've gone through professional development courses so they know what lymphoedema is and what peripheral neuropathy.

Kellie Curtain [00:18:51] And that helps isn't it because when you've got someone that actually knows about some of the issues that women and men with breast cancer have. And I guess also puts to bed some of the excuses. Oh I've got to I've got a sore back or I've got this. There is something there's always something someone can do?

Prue Cormie [00:19:11] Always. We can always do a work around. So and if you go and see these people they can either have a straight you can pick up the phone and call them straight away without a referral. You can actually go and to your general practitioner, your GP, for what's called a chronic disease management plan and that way those services can be subsidized through Medicare, private health insurance now will subsidize some.

Kellie Curtain [00:19:33] Fantastic because it all adds up doesn't it.

Jo Francis [00:19:35] Yes it does and these are the things I think we need to be aware of. Because even myself I'm not aware that I could get some of these services which I would in a heartbeat to be honest. So knowing somebody that's maybe specialized in reconstruction from a diep like that would really be beneficial to me. And getting core strength and getting my heart back to you know after all the treatments. So it's good to know that you guys are around.

Prue Cormie [00:19:56] And you know you've just identified a whole bunch of things that are really unique to... a unique skillset. And how do you work around those with exercise knowing that hey maybe the chemotherapy is actually aged your heart quite rapidly. You know maybe the hormone therapy to you on stripping away your bone quality. You know maybe your shoulders haven't recovered very well after that 10 hour surgery. And you know those types of things are what if you go and seek out professional advice you'll be able to not only do the right exercise for you, you'll be able to do it in the right way in the sense that you can continue to exercise and manage your own exercise program or get involved in a program that is supervised and you can have more more contact.

Jo Francis [00:20:39] I'm going back on tamoxifen soon I actually took myself off for personal reasons and a lot of the women I've spoken to who are now coping with the side effects that I've had. I thought after chemo and a double mastectomy I'll be fine to take this little white pill but to be honest it's been very difficult and yep everything. And the one thing that I am doing is looking into exercise because I know I'll be mentally strong I'll be physically strong to deal with what comes next. And yes so that's one really important thing for me moving for when I'm about to take the tamoxifen again that I get back on to my physical it.

Prue Cormie [00:21:17] Again is the best medicine you can take. Alongside the tamoxifen.

Jo Francis [00:21:20] Which I wasn't doing before and I think that that had a bit of a detrimental effect as well.

Kellie Curtain [00:21:25] So what about during active treatment? We've heard quite a few stories of women that are exercising even that little bit more just prior to a chemotherapy session. Could it actually enhance the effects of your chemo treatment?

Prue Cormie [00:21:47] So the simple answer to that is we don't know yet. So there's not enough research to say can exercise potentially enhance the efficacy or the value of that chemotherapy. There's a lot of theories around how that may happen but we don't yet know. So what we do know from the research evidence though is that women who exercise during their radio their chemotherapy actually can tolerate greater dosages of that chemotherapy and then have less dose modifications. Meaning that you basically you can manage your side effects better. So irrespective of what time of day you do that in relation to your chemo if you're exercising during your chemotherapy regime you actually can tolerate that better.

Kellie Curtain [00:22:31] So you bounce back quicker.

Prue Cormie [00:22:32] And you can actually get more cancer killing drugs. So the potential ability of the chemotherapy to then slow the growth of that cancer and prevent spread is then much higher because you're getting a high dosage.

Kellie Curtain [00:22:46] Did you know that Jo?

Jo Francis [00:22:47] No. I wish I had known this first time round because it would have been I would have been on board that was for sure.

Prue Cormie [00:22:53] And it's really interesting about that data is that resistance exercise in that space become really really important. So it's not just doing your cardio going out for a walk. It's actually lifting weights during that time that we see the most pronounced benefit. And there's a whole lot of stuff that goes on within, you know, when you when you actually we look at mice and we research mice or we we look at what happens inside the cells and around the tumours and there's a whole bunch of things that are happening with people who are exercising versus not exercising. That may lead us to believe that something with exercise is actually influencing the way that the cancer cells spread.

Jo Francis [00:23:31] I've noticed in it where I'm having my treatment at Peter Mac they actually have a gym there now for people with going undergoing treatment and they're having their chemo and going in there and having a walk or run or whatever it is that they want to do. And I've never seen that before I was introduced to it maybe about six months ago.

Prue Cormie [00:23:49] Absolutely. And that's that's certainly the advice. As soon as you can start exercising close to the diagnosis as is possible. That's great. And if you can maintain exercise during chemotherapy which is really hard and challenging but you'll actually be able to. You won't experiences as bad side effects as you had the first time around.

Kellie Curtain [00:24:09] It must also aid sleep which is a huge problem for so many people with breast cancer because poor sleep has that cumulative effect. Whether it's because of lymphoedema, reconstruction poor sleep just begets poor sleep. And exercise has got to be great for sleep. 

Prue Cormie [00:24:32] Yes. We don't know enough in in breast cancer patients around how exercise influences sleep quality. What we know is from some self report so from from people actually saying I think my sleep is better. Following exercise during you know after breast cancer. So I think where there's there's a lot more work we need to do to really understand how and why that can happen. But certainly from understanding what how exercise influences sleep outside the cancer space we know that there's a really positive association with enhancing sleep quality.

Kellie Curtain [00:25:06] And so if you're doing the right sort of exercises during active treatment how does that then transition to post treatment and well beyond?

Prue Cormie [00:25:19] So if basically you won't experience a severe treatment related side effect. So when you finish Jo your your treatment and you are trying to then build back up to eventually getting to play netball again that would have been much quicker if you were able to exercise throughout. So instead of like going into a deep dip of a whole range of different symptoms you actually don't get that far down so you can bounce back a lot better. Certainly if you can maintain that level of exercise and eventually increase it as you're feeling better. We know that what that means in terms of preventing recurrence and preventing potentially other cancers, other chronic diseases such as heart disease and diabetes and obesity it's going to be extremely important to maintain that exercise.

Kellie Curtain [00:26:05] Is it ever too late to start?

Prue Cormie [00:26:07] Never never. And it doesn't matter what level you start today and you start where you're at and then you just progress from there. And the progressions sometimes will just be maybe you know tomorrow I walk a minute longer than I did today or a little bit faster. There's gonna be days where you don't feel very good. I don't have breast cancer and there's plenty of days that I don't want to exercise and I do this for a living! That's just that's normal. So you know it's start where you're at today. Try and progress and listen to your body and understand that there's some days that you won't be able to do as much as you may like to do.

Kellie Curtain [00:26:42] So it really is the magic pill exercise.

Prue Cormie [00:26:45] Well it certainly has a lot of effects for physiological, mental, socially to our overall well-being that I think you could... You would be hard pressed to find anything that's better than exercise to help support people through their their cancer treatment.

Kellie Curtain [00:27:04] Jo the final word to you that the difference that it's made to your life.

Jo Francis [00:27:08] Oh this time round  it's chalk and cheese to be honest. The first time was just it was a whirlwind of emotions. I was not the Jo that everybody knew. And this time round I think that being able to or being told by the professionals that it was in my best interest to exercise has made a huge difference. And like you said before even just socially being around other people doing it has been great. And just something for yourself. I mean you go to hell and back and it is something just for yourself but it also enhances my life at home with my children my husband and outside of that. And I think you know there's nothing better. And you know when you've been given a cancer diagnosis you know there's no time like the present. And I'm one of the lucky ones to still be here so I might as well make the most of it while I've got the chance. 

Kellie Curtain [00:27:54] And a word of encouragement for someone who just doesn't feel like getting off the couch?

Jo Francis [00:27:57] Oh look I've been there believe me I was there for years. And it's it's funny like I'll come home from a game of netball and I'll say to my husband every time oh my God I feel so good. I don't know what you know what it is and he's like this is this is you! This is what you like to do. I think and like you said before slow steps you know that's it. Just walk an extra minute every day and then you might actually begin to enjoy it.

Prue Cormie [00:28:18] But you've just articulated what we can't do in the science. So many of our participants in our programs talk about the intangibles of exercise and that's that they actually move beyond being a patient and get back to living again. So it's re-finding who you are as a person. Being able to re-engage in in your work life, your family life, your social life. These are things that exercise gives you.

Jo Francis [00:28:45] And sometimes we have all the excuses in the world like you said before. I can't lift a weight I've got lymphoedema. Well actually yeah you can and if you do it's going to help your lymphedema. So I know that for a fact.

Kellie Curtain [00:28:57] Thank you. Prue and Jo for being upfront with us about exercise and breast cancer an episode made possible with thanks to Dry July. If you would like more information about exercising when you have breast cancer. There are links to resources on our Web site BCNA. Dot org dot Are you the opinions of our guests are very welcome but not necessarily shared by BCNA. If you have any individual concerns please contact a health professional We'd love to know what you think about podcast series so please leave us a writing and review on Apple Podcasts. Until next time, I'm Kellie Curtain. Thanks for being Upfront with us.